Which plan is right for you?
Below you can compare coverage for Dominion's plans. For more details, you can view the plan documents at the bottom of the chart. The "Percentages" tab below shows how much each of the plans cover for each of the listed procedures. Click the "Copayments" tab to see a in-network comparison that shows how much you would pay for these procedures for each of these plans.
| Benefit Features | Select Plan Basic 1 | PPO Preventive | PPO Basic | |||
| Office Visit | $10 | N/A | N/A | |||
| Deductibles | None | $50 per adult (adult max $150)3 | $50 per adult (adult max $150)3 | |||
| Annual Maximums | None | None | $1,000 per insured person | |||
| Waiting Periods | None | None | None | |||
| Receive Care From | Select Plan Network Dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, OH, WI) or any licensed dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, WI) or any licensed dentist | |||
| States Available | DC, DE, MD, NJ, PA, VA | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ, OH, OR, PA, VA, WI | DC, DE, FL, GA6, IL, IN, MD, MI, MO, NC, NJ7, OR, PA, VA, WI | |||
| Procedures and Covered Services | In-Network | In-Network | Year 1 2 In/Out Network |
Year 2 2 In/Out Network |
Year 3 2 In/Out Network |
|
| I. Diagnostic & Preventive | ||||||
| Comprehensive Oral Exam | 100% | 100% | 80% | 100% | 90% | 100% | 90% | 100% | 90% | |
| Bitewing X-Rays (4 Films) | 100% | 100% | 80% | 100% | 90% | 100% | 90% | 100% | 90% | |
| Teeth Cleaning (Adult) | 90% | 100% | 80% | 100% | 90% | 100% | 90% | 100% | 90% | |
| II. Basic Restorative | ||||||
| Full and panoramic X-rays | 85% | 100% | 80% | 50% | 30% | 60% | 50% | 80% | 70% | |
| Amalgam filling (silver) | 80% | 0% | 0% | 50% | 30% | 60% | 50% | 80% | 70% | |
| Composite filling (white) | 75% | 0% | 0% | 50% | 30% | 60% | 50% | 80% | 70% | |
| Extraction, erupted tooth | 70% | 0% | 0% | 50% | 30% | 60% | 50% | 80% | 70% | |
| III. Major Restorative | ||||||
| Crown (Porcelain/Metal) | 60% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| Bridges | 65% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| Complete Denture | 70% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| Relining of dentures | 65% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| Periodontics (root planing and therapy) | 70% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| Endodontics (root canals) | 70% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| Oral Surgery (extraction of impacted teeth) | 70% | 0% | 0% | 15% | 10% | 25% | 20% | 50% | 40% | |
| IV. Orthodontics | ||||||
| Adults | 40% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |
| Plan Document | PPO Preventive PPO Basic Kids |
|||||
Additional Plans
| Benefit Features | Select Plan Premium1 | PPO Plus | PPO Premium | Elite ePPO Basic | ||
| Office Visit | $10 | None | None | None | ||
| Deductibles | None | $50 per adult (adult max $150)3 | $50 per adult (adult max $150)4 | $25 per adult (adult max $75)4 | ||
| Annual Maximums | None | $1,000 per insured person | $1,500 per insured person | $1,500 per insured person | ||
| Waiting Periods | None | None | Yes5 | None | ||
| Receive Care From | Select Plan Network Dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, OH, WI) or any licensed dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, OH, WI)) or any licensed dentist | Elite ePPO Network Dentist | ||
| States Available | DC, DE, MD, NJ, PA, VA | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ, OH, OR, PA, VA, WI | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ, OH, OR, PA, VA, WI | DC, MD, PA, VA | ||
| Procedures and Covered Services | In-Network | In/Out Network | In/Out Network | In-Network | ||
| I. Diagnostic & Preventive | ||||||
| Comprehensive Oral Exam | 100% | 100% | 90% | 100% | 90% | 100% | ||
| Bitewing X-Rays (4 Films) | 100% | 100% | 90% | 100% | 90% | 100% | ||
| Teeth Cleaning (Adult) | 100% | 100% | 90% | 100% | 90% | 100% | ||
| II. Basic Restorative | ||||||
| Full and panoramic X-rays | 85% | 100% | 90% | 100% | 90% | 100% | ||
| Amalgam filling (silver) | 85% | 50% | 40% | 80% | 70% | 90% | ||
| Composite filling (white) | 75% | 50% | 40% | 80% | 70% | 90% | ||
| Extraction, erupted tooth | 75% | 50% | 40% | 80% | 70% | 80% | ||
| III. Major Restorative | ||||||
| Crown (Porcelain/Metal) | 60% | 0% | 0% | 50% | 40% | 60% | ||
| Bridges | 65% | 0% | 0% | 50% | 40% | 60% | ||
| Complete Denture | 70% | 0% | 0% | 50% | 40% | 75% | ||
| Relining of dentures | 70% | 0% | 0% | 50% | 40% | 80% | ||
| Periodontics (root planing and therapy) | 70% | 50% | 40% | 50% | 40% | 70% | ||
| Endodontics (root canals) | 70% | 0% | 0% | 50% | 40% | 50% | ||
| Oral surgery (extraction of impacted teeth) | 70% | 0% | 0% | 50% | 40% | 70% | ||
| IV. Orthodontics | ||||||
| Adults | 40% | 0% | 0% | 0% | 0% | 0% | ||
| Plan Document | Select Plan Premium Select Plan Premium Kids |
Elite ePPO Basic PPO Basic Kids |
||||
1 Based on the Context4Healthcare’s 80th percentile. Coverage for orthodontia is based on the 80th percentile of Dominion's out-of-network claims data for D8080 and D8090 (excluding Invisalign) from 2015 to 2018. Based on zip 223. A specific fee schedule applies and will be sent with your membership card. To view copay schedules for the pediatric plans, go to DominionNational.com/pediatric.
2 Year 1 benefits apply during the subscriber's first 12 months of continuous coverage. Year 2 benefits apply during the subscriber's second 12 months of continuous coverage. Year 3 benefits apply during the subscriber's third 12 months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.
3 Deductibles apply to all services.
4 Deductibles apply to basic care and major restorative care.
5 There are no waiting periods for diagnostic and preventive care. To be eligible for basic care, you must have completed 6 (six) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 (twelve) months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.
6 PPO plans in Georgia: out-of-network coinsurance is the same as the in-network coinsurance. Note when using an out-of-network provider, members may incur any charges exceeding the allowed amount.
7 In New Jersey, Year 1 Major Restorative Care coinsurance is 30% in-network and 25% out-of-network. Year 2 Major Restorative Care coinsurance is 40% in-network and 30% out-of-network.
Which plan is right for you?
Below you can compare in-network coverage for Dominion's plans. For more details, you can view the plan documents at the bottom of the chart. The "Copayments" tab below shows how much you would pay for these procedures for each of these plans. Click the "Percentages" tab to see a comparison that shows how much each of the plans cover for each of the listed procedures.
| Benefit Features | Select Plan Basic | PPO Preventive | PPO Basic | ||||
| Office Visit | $10 | N/A | N/A | ||||
| Deductibles | None | $50 per adult (adult max $150)3 | $50 per adult (adult max $150)3 | ||||
| Annual Maximums | None | None | $1,000 per insured person | ||||
| Waiting Periods | None | None | None | ||||
| Receive Care From | Select Plan Network Dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, OH, WI) or any licensed dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, WI) or any licensed dentist | ||||
| States Available | DC, DE, MD, NJ, PA, VA | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ, OH, OR, PA, VA, WI | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ, OR, PA, VA, WI | ||||
| Procedures and Covered Services | Avg. Cost Without Plan1 | You Pay | You Pay | You Pay Year 11,2 In-Network |
You Pay Year 21,2 In-Network |
You Pay Year 31,2 In-Network |
|
| I. Diagnostic & Preventive | |||||||
| Comprehensive Oral Exam | $73 | $0 | $0 | $0 | $0 | $0 | |
| Bitewing X-Rays (2 Films) | $62 | $0 | $0 | $0 | $0 | $0 | |
| Teeth Cleaning (Adult) | $122 | $13 | $0 | $0 | $0 | $0 | |
| II. Basic Restorative | |||||||
| Filling (3-Surface/Silver) | $345 | $64 | Not covered | $169 | $135 | $68 | |
| Complete Series X-Rays | $190 | $26 | $0 | $95 | $76 | $38 | |
| III. Major Restorative | |||||||
| Crown (Porcelain/Metal) | $1,278 | $523 | Not Covered | $1,097 | $968 | $646 | |
| Complete Denture | $2,218 | $697 | Not Covered | $1,839 | $1,623 | $1,082 | |
| Root Canal (Anterior Tooth) | $1,157 | $341 | Not Covered | $964 | $851 | $567 | |
| Perio Scaling/Root Planing | $346 | $109 | Not Covered | $291 | $257 | $171 | |
| IV. Orthodontics | |||||||
| Adults | $6,330 | $3,658 | Not Covered | Not Covered | Not Covered | Not Covered | |
| Plan Document | PPO Preventive PPO Basic Kids |
||||||
Additional Plans
| Benefit Features | Select Plan Premium | PPO Plus | PPO Premium | Elite ePPO Basic | |||
| Office Visit | $10 | None | None | None | |||
| Deductibles | None | $50 per adult (adult max $150)3 | $50 per adult (adult max $150)4 | $25 per adult (adult max $75)4 | |||
| Annual Maximums | None | $1,000 per insured person | $1,500 per insured person | $1,500 per insured person | |||
| Waiting Periods | None | None | Yes5 | None | |||
| Receive Care From | Select Plan Network Dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, OH, WI) or any licensed dentist | Elite PPO network dentist (DC, DE, MD, PA, VA), Choice PPO network dentist (FL, GA, IL, IN, MI, MO, NC, NJ, OR, OH, WI) or any licensed dentist | Elite ePPO Network Dentist | |||
| States Available | DC, DE, MD, NJ, PA, VA | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ, OH, OR, PA, VA, WI | DC, DE, FL, GA6, IL, IN, MI, MO, MD, NC, NJ OH, OR, PA, VA, WI | DC, MD, PA, VA | |||
| Procedures and Covered Services | Avg. Cost Without Plan1 |
You Pay | You Pay1 | You Pay1 | You Pay | ||
| I. Diagnostic & Preventive | |||||||
| Comprehensive Oral Exam | $73 | $0 | $0 | $0 | $0 | ||
| Bitewing X-Rays (2 Films) | $62 | $0 | $0 | $0 | $0 | ||
| Teeth Cleaning (Adult) | $122 | $0 | $0 | $0 | $0 | ||
| II. Basic Restorative | |||||||
| Filling (3-Surface Silver) | $345 | $58 | $169 | $68 | $40 | ||
| Complete Series X-Rays | $190 | $26 | $0 | $0 | $0 | ||
| III. Major Restorative | |||||||
| Crown (Porcelain/Metal) | $1,278 | $495 | Not covered | $646 | $570 | ||
| Complete Denture | $2,218 | $664 | Not covered | $1,082 | $560 | ||
| Root Canal (Anterior Tooth) | $1,157 | $325 | Not covered | $567 | $550 | ||
| Perio Scaling/Root Planing | $346 | $105 | $171 | $171 | $97 | ||
| IV. Orthodontics | |||||||
| Adults | $6,330 | $3,658 | Not Covered | Not Covered | Not Covered | ||
| Plan Document | Select Plan Premium Select Plan Premium Kids |
PPO Plus |
PPO Premium PPO Premium Kids |
Elite ePPO Basic | |||
1 Based on the Context4Healthcare’s 80th percentile. Coverage for orthodontia is based on the 80th percentile of Dominion's out-of-network claims data for D8080 and D8090 (excluding Invisalign) from 2015 to 2018. Based on zip 223. A specific fee schedule applies and will be sent with your membership card. To view copay schedules for the pediatric plans, go to DominionNational.com/pediatric.
2 Year 1 benefits apply during the subscriber's first 12 months of continuous coverage. Year 2 benefits apply during the subscriber's second 12 months of continuous coverage. Year 3 benefits apply during the subscriber's third 12 months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.
3 Deductibles apply to all services.
4 Deductibles apply to basic care and major restorative care.
5 There are no waiting periods for diagnostic and preventive care. To be eligible for basic care, you must have completed 6 (six) months of continuous coverage. To be eligible for major restorative care, you must have completed 12 (twelve) months of continuous coverage. Waiting period credit will be given for the length of time an insured was covered under each benefit classification under the current employer's prior dental coverage.
6 PPO plans in Georgia: out-of-network coinsurance is the same as the in-network coinsurance. Note when using an out-of-network provider, members may incur any charges exceeding the allowed amount.
7 In New Jersey, Year 1 Major Restorative Care coinsurance is 30% in-network and 25% out-of-network. Year 2 Major Restorative Care coinsurance is 40% in-network and 30% out-of-network.
AFFILIATIONS AND RECOGNITION
